Highlights of Noteworthy Decisions

Decision 1122 21
Z. Onen - M. Falcone - C. Salama
  • Consequences of injury (iatrogenic illness) (treatment) (surgery)
  • Disablement (repetitive work)
  • Trigger finger
  • Casino employment (card dealer)
  • Loss of earnings {LOE} (eligibility) (impairment)
  • Second Injury and Enhancement Fund {SIEF} (pre-existing disability) (causation)
  • Preexisting condition (carpal tunnel syndrome)

The issues under appeal in this employer appeal were: whether the worker had initial entitlement for a left third trigger finger as a result of work performed as a dealer in a casino, and entitlement to benefits for loss of earnings (LOE) due to the trigger finger release surgery of April 1, 2016. In the alternative, the employer sought relief from the costs of the worker's injury under the Second Injury and Enhancement Fund (SIEF) at the rate of 75%.

The employer's appeal was denied.
The Panel concluded that the worker had entitlement to benefits for left middle trigger finger as a result of the very frequent repetitive use of his fingers while employed as a casino dealer. The evidence demonstrated that repetitive work using the fingers is consistent with trigger finger, and there is greater risk that trigger finger can develop after activity that strains the hand.
The ergonomic studies submitted by the employer showed that on opening the game of Blackjack, the dealer deals about 338 cards in 12 minutes or one card every .5 seconds. This involves removing the card from the shoe, placing it on the table face down and sliding it to the player across from the dealer. The left hand is used exclusively for removing the cards from the shoe while dealing the hand. The cards are removed from the shoe with a pinching motion of the thumb, index finger and middle finger. The worker spent about 50% of his work day dealing blackjack. The employer's Physical Demands Analysis (PDA) showed that the frequency requirements for Blackjack are: 3/5 for grip, 4/5 for two and three finger pinch, 4/5 for handling and 3/5 for finger use. The frequency for the games, Pai Gow, Omaha and Texas Hold'em, which the worker also dealt, had the same high level of frequency for repetitive finger movement for two and three finger pinch and handling.
Furthermore, the employer submitted that the worker's rest breaks every hour would have mitigated any risk of injury as a result of the frequent activity. It was referred to by a medical expert as a "robust" break schedule. The Panel noted that the Potvin and Saindon studies pointed to breaks as a mitigating factor for the physical stresses identified in the reports for the job of Blackjack dealer. The Panel noted further that breaks are helpful to provide a period of recovery for the muscles, tendons and sheaths; however, they are not a guarantee that no injury will occur as a result of a high rate of repetitive activity. They function as a risk management measure given the high levels of repetitive activity, and the presence of breaks does not directly lead to the conclusion that no injury can occur. The Panel also recognized that not all muscle, tendon and sheath structures can be expected to recover at the same rate in all individuals. In the circumstances of this case, the worker was in an age range that placed him at risk of trigger finger injury. He was engaged in work activity that demanded significant hand and finger activity requiring speed and dexterity, and he performed this work for many years. In the Panel's assessment, the worker's continued and highly repetitive and rapid finger and hand movements, the evidence pointing to compatibility between trigger finger and repetitive finger movements, and the worker's risk factors, outweighed the mitigating factors offered by the break cycles.
Additionally, the Trigger Finger Etiology article set out the risk factors for developing trigger finger including: age in the middle fifth and sixth decades of life, female gender, diabetes, and the development of carpal tunnel syndrome. It was noted in a medical report that there is a "slight correlation" between carpal tunnel syndrome and trigger finger but "...the general expert opinion is that one does not contribute to the other." The Panel understood this to mean that it has not been shown in the medical literature that the presence of carpal tunnel syndrome can lead to trigger finger, but it is possible that they are both related to the same or similar causes. At the time of his diagnosis, the worker was 42 years old and therefore in the early years of the fifth decade. He was in the age range for greater incidence of trigger finger. He also had a diagnosis of bilateral carpal tunnel for which he was receiving conservative treatment involving splints; however, the Panel determined that CTS was unlikely to be a contributor to the onset of trigger finger in the absence of release surgery.
The Panel concluded that, on a balance of probabilities, the evidence supported the conclusion that the worker's work activity was a significant contributor to the onset of left middle trigger finger diagnosed in December 2015. The worker had entitlement for a third middle trigger finger disablement injury, which required surgery on April 1, 2016. The Panel found that the worker was entitled to consideration of LOE benefits for lost time resulting from the injury, including the April 1, 2016 surgery and its sequelae. The nature and extent of any loss of earnings resulting from the injury was remitted to the Board for determination.
With respect to the employer's request for SIEF relief, the evidence indicated that there is a possible association between the presence of carpal tunnel syndrome with no surgical repair, and trigger finger - but it is unlikely to be causal. The review set out in Decision No. 184/18I indicates that Tribunal decisions have generally accepted that the medical literature supports a relationship between carpal tunnel surgery and the onset of trigger finger following that procedure. The Panel, however, agreed that the relationship between carpal tunnel syndrome and trigger finger is likely an association and it is not causal. The evidence therefore did not show the worker had a pre-existing disability that contributed to the onset of trigger finger within the meaning of the SIEF policy. The employer's request for SIEF relief was denied.